Total intravenous anesthesia in kidney transplantation: A narrative review

Table 4 Transplant-specific implications of propofol-based total intravenous anaesthesia vs volatile anaesthesia in kidney transplantation

Aspect	TIVA (propofol-based)	Volatile (sevoflurane/isoflurane/desflurane)	Clinical implication in kidney transplantation
Effect at reperfusion	Modest vasodilatation; SVR drops; manageable with norepinephrine and balanced crystalloid	Stable SVR; theoretical preconditioning via mitochondrial KATP channels	Both techniques are safe at unclamping when fluid and vasopressor support are titrated; no signal of reperfusion-related haemodynamic collapse with either
Tubular injury biomarkers (KIM-1, NAG)	Lower urinary concentrations in VAPOR-1 (n = 57 LDKT pairs)	Higher urinary concentrations in VAPOR-1	Biomarker signal favouring TIVA at the molecular level in a single small LDKT trial; not yet translated into hard clinical endpoints
Time to extubation and recovery quality	Faster (favourable context-sensitive half-time); often combined with remifentanil	Slower (pulmonary elimination, tissue accumulation); often combined with fentanyl in published comparisons	Earlier ICU step-down with TIVA, but recovery comparisons are confounded by opioid choice (see Discussion)
PONV incidence	Significantly lower (intrinsic anti-dopaminergic and 5-HT3 antiemetic effect)	Higher	Reliable early oral tacrolimus and MMF absorption—clinically important for stable trough levels in the most immunologically vulnerable post-operative phase
Acute rejection risk	Non-significant numerical trend to higher rejection in propofol arm of VAPOR-1 only; not replicated	No significant signal	No compelling evidence that anaesthetic maintenance meaningfully alters rejection risk
DGF/1-year graft survival	No demonstrated difference	No demonstrated difference	Hard clinical endpoints comparable; LDKT-dominant evidence limits generalisability to ECD/DCD recipients
Recipient-specific safety	Injection pain; hypertriglyceridaemia (lipid emulsion); rare PRIS with prolonged infusion; bacterial-contamination risk; awareness risk (no end-tidal monitoring)	Historical concern re compound A (sevoflurane in low-flow systems) now considered low-risk; end-tidal MAC monitoring straightforward	Both safe in modern practice; TIVA requires vigilance in dyslipidaemic, diabetic, or pancreatitis-prone recipients
Quality of direct KT evidence	Six small studies (< 200 recipients total); LDKT-dominant; era-heterogeneous	Same evidence pool	Conclusions for both techniques are constrained by the same small, low-risk evidence base
Practical infrastructure	TCI pump, pharmacokinetic-pharmacodynamic models, processed-EEG monitoring (e.g., BIS) for awareness mitigation	Vaporiser, end-tidal MAC monitoring	Volatile may be the practical default in resource-limited transplant programmes; TIVA preferred where TCI and processed-EEG are available

TIVA: Total intravenous anaesthesia; SVR: Systemic vascular resistance; KIM-1: Kidney injury molecule-1; NAG: N-acetyl-β-D-glucosaminidase; LDKT: Living-donor kidney transplant; ICU: Intensive care unit; PONV: Postoperative nausea and vomiting; MMF: Mycophenolate mofetil; DGF: Delayed graft function; PRIS: Propofol infusion syndrome; MAC: Minimum alveolar concentration; ECD: Extended-criteria donor; DCD: Donation-after-circulatory-death; KT: Kidney transplant; TCI: Target-controlled infusion; EEG: Electroencephalographic; BIS: Bispectral index.